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76 Ocean Blvd RES20-0257 Use of Private Provider5561 Florida Mining Blvd Jacksonville, FL 32257 904-296-0757 — Fax: 904-296-0748 NOTICE TO BUILDING OFFICIAL — USE OF PRIVATE PROVIDER Project Name:7 1702-7-(a ^ - ©GE AV e>1^Y'P _ Plans Review Inspections Both t[ Parcel Tax I.D d 2- ^ 0110 Circle one Note_ If the notice applies to either private plan review or private inspection services the Building Official may require, at his or her discretion, the private provider to be used for both services pursuant to Section 553.791(2) Florida Statute. C ANPlGE NOL-L-- the D6_!tthe fee owner, affirm I have entered into a contract with the Private Provider Indicated belowto conduct the services indicated above. Private Provider Firm: Universal Enr;ineerinr Sciences Inc. FL. License Re Jstration or Certificate No. P.E. 38705 Private Provider: Richard G. Kushner P -E. Address: 5561 Florida Minim Blvd, Jacksonville, FL 32251 Phone: 904-296-0757 Fax 904-296-0748 I have elected to use one or more private providers to provide building code plans review and/or inspection services on the building that is the subject of the enclosed permit application, as authorized by s.553.791, Florida Statutes. I understand that the local building official may not review the plans submitted or perform the required building inspections to determine compliance with the applicable codes, except to the extent specified in said law. Instead, plans review and/or required building inspections will be performed by licensed or certified personnel identified in the application. The law requires minimum insurance requirements for such personnel, but I understand that I may require more insurance to protect my interests. By executing this form, I acknowledge that I have made inquiry regarding the competence of the licensed o certified personnel and the level of their insurance and am satisfied that my interests are adequately protected. I agree to indemnify, defend, and hold harmless the local government, the local building official, and their building code enforcement personnel from any and all claims arising from my use of these licensed or certified personnel to perform building code inspection services with respect to the building that is the subject of the enclosed permit application. I understand the Building Official retains authority to review plans, make required inspections, and enforce the applicable codes vothin his or her charge pursuant to the standards established by s.553.791, Florida Statutes. If I make any changes to the listed private providers or the services to be provided by those private providers, I shall, within 1 business day after any change, update this notice to reflect such changes. The building plans review and/or inspection services provided by the private provider is limited to building code compliance and does not include review for fire code, land use environmental or other codes INDIVIDUAL CORPORATION PARTNERSHIP Print Individual Name Print Corporation Name Print Partnership Name By: , By: By: (signature) (signature) Printn j Name: APNce ' u0L-1- Print Name: Print Name: Its: Its: Address: Address: Address- TelephoneTelephone 7/ 3 No: -los "2323 No.: Telephone No.: Please use appropriate notary bloc F- . STATE OF -�10d S COUNTY OF A J - Individual Be ore me. this t7 day of 20 aV perschally appeared who executed the foregoing instrument. and acknowledged before me that same was executed for the purposes therein expressed. Corporation Before me, this day of , 20_, Corporation, on behalf of the state corporation who executed the foregoing instrument, and acknowledged before me that same was executed for the purposes therein expressed. Partnership Before me, this day of ,20 personally appeared Partner/agent on behalf of, a partnership, who executed the foregoing instrument, and acknowledged before me that same was executed for the purposes therein expressed. Personally known or, produced identification Type of identification produced Signature of Notary Print Name C� r� Notary Public: NOTARY STAMP BELOW My commission expires: t I- MONICA L MARTINS NOTARY PUBLIC STATE OF RHODE ISLAND NOTARY ID# 756537 MY COMMISSION EXPIRES 04/28/2022'